How do you refuse (controlled) prescriptions?

[pharmacita0101]

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I work in an area where some practitioners are known to write controls excessively. My question is what do you tell a patient when you decide you don't want to fill a script for them? Also, how does the dea fit into these situations? Thanks all!

 

[Promethean]

"I'm not comfortable filling this prescription. I am concerned because... (insert reason you don't want to fill the script.)"

I've had a pharmacist refuse to fill a prescription* for me and that was how she went about it. I thanked her for her trouble, took my prescription back and found a different pharmacy... which is pretty much what will happen if you refuse to fill. Some people might get more impolite about it than others, but basically, you have a right and a responsibility not to fill a prescription if you have concerns about it that you can't resolve with the patient or the prescriber. You might lose some customers, but if you truly believe that the alternative is to provide excessive amounts of controlled substances, then losing those customers might be a good thing.

*Testosterone, a schedule III drug, not a narcotic. I've been on a steady low dose for many years, and only had trouble getting it filled a couple of times.

 

[npage148]

We don't have it. The other chain down the street has it in stock. I just called them to xheck

 

[zelman]

"I'm not comfortable filling this prescription. I am concerned because... (insert reason you don't want to fill the script.)"

I've had a pharmacist refuse to fill a prescription* for me and that was how she went about it. I thanked her for her trouble, took my prescription back and found a different pharmacy... which is pretty much what will happen if you refuse to fill. Some people might get more impolite about it than others, but basically, you have a right and a responsibility not to fill a prescription if you have concerns about it that you can't resolve with the patient or the prescriber. You might lose some customers, but if you truly believe that the alternative is to provide excessive amounts of controlled substances, then losing those customers might be a good thing.

*Testosterone, a schedule III drug, not a narcotic. I've been on a steady low dose for many years, and only had trouble getting it filled a couple of times.

It's a C2 in NY, for whatever that's worth.

 

[Promethean]

We don't have it. The other chain down the street has it in stock. I just called them to xheck

Cute as a joke. Not terribly believable IRL, especially if you are talking something like oxycodone or other commonly (over) prescribed narcs. And you lose the opportunity to just be candid, which has the potential to lead to a useful conversation.

It's a C2 in NY, for whatever that's worth.

Holy poop! It is hard enough to get it as a C3! I mean, I see why it has to be like this, but it does suck to be made to feel like a criminal for wanting to have a functional endocrine system.

 

[BidingMyTime]

Honesty is the best policy. I tell them I can not fill their prescription until I can contact their doctor because of my concerns, or that I can not fill their prescription until such and such a date because of excessive usage. They can either wait, or take their script to another pharmacy (or come back on a different shift when I'm gone and try their luck with the new pharmacist on duty.) Just be polite, there is no need to act like they are a drug seeker or junkie or anything. Just honestly state your concerns and what conditions would have to be met for you to fill the prescription. Don't argue with them, just state the facts.

 

[midweststudent1]

I'm a first year med student here, but I've worked in a pharmacy before, but in a very small town where we knew all the docs really well. Things will be different for me, assuming none of the pharmacists will really know me.

If I'm prescribing narcotics for a patient, what can I do to alleviate a pharmacists concerns?

 

[zelman]

I'm a first year med student here, but I've worked in a pharmacy before, but in a very small town where we knew all the docs really well. Things will be different for me, assuming none of the pharmacists will really know me.

If I'm prescribing narcotics for a patient, what can I do to alleviate a pharmacists concerns?

Respond to phone calls.
Don't prescribe drugs you don't understand.
If your patient takes very high opiate doses, don't give them exclusively IR forms.
If you're thinking about prescribing something atypical (Avinza, Opana, Nucynta, etc) call the pharmacy and have a conversation with the pharmacist about product availability and maybe even dialog about their thoughts on the patient case and product selection.
Get set up for electronic prescribing of controlled substances.

 

[pharmacita0101]

Thank you for your relies. One other question...inevitably there will be that one patient who just doesn't understand and gets upset and wants to complain. If this has ever happened to what, if anything, is done about it?

 

[WVUPharm2007]

CVS doesn't get in the way of a pharmacists' right to refuse narcotics due to that whole mess in Florida. If the drug seeker calls corporate, corporate will tell them there is nothing they can do about it, each pharmacist has autonomy in how they determine whether or not a controlled substance is being used for a legitimate medical purpose.

So this allows me to just be totally honest within the confines of the controlled substance policy of CVS. Which states that I can refuse for reasons as minimal as I suspect things aren't quite right.

 

[Promethean]

Thank you for your relies. One other question...inevitably there will be that one patient who just doesn't understand and gets upset and wants to complain. If this has ever happened to what, if anything, is done about it?

This is a situation where pretty much any employer is going to have to back you. The whole point of having a highly trained professional be the gatekeeper for prescription drugs is so that you can decide when filling the prescription is the wrong thing for the patient. Otherwise, there would be no reason not to be replaced by a vending machine.

It does all come back to the patient. Just as you wouldn't fill an script for a massive overdose of warfarin or digoxin, because it could harm the patient, that should be your reason for not giving dispensing unusually large amounts of instant release opiate. Not because you are fighting the war on drugs, but because you care about not contributing to the harm of your patient.

When you have that goal at heart, it is easy to be polite, firm, and yet still compassionate. When you come at it from that spirit, saying, "No, I won't give you what you are asking for, because I am concerned that it could be harmful to you." You will have a lot fewer irate customers. But even when there is that one, you will be in the right. Even if you did get fired or reprimanded for doing the right thing, that would be better than to fill a script that lead to patient harm.

 

[doublehh03]

Thank you for your relies. One other question...inevitably there will be that one patient who just doesn't understand and gets upset and wants to complain. If this has ever happened to what, if anything, is done about it?

Let that complain. Getting a complaint on narcotics or controlled substances should be the least of your concerns.

 

[WVUPharm2007]

Let that complain. Getting a complaint on narcotics or controlled substances should be the least of your concerns.

Literally the least of your concerns. As long as you are professional in your demeanor -- they will not touch it.

 

[icekitsune]

Since this topic was brought up, i have a question on a situation. My fellow rph was telling me about his situation. He works at PT at a independent where each customer is pretty impt. His partner is willing to fill C2 in NY the day patients come in from their appointment because they live far away and small town mentality. Apparently everyone knows the manager. The patient's appointment is set up every 27 or 28 days so i guess the pt wants to fill it the day of the apt for convenience sakes so my friend who is a new grad doesn't know what he should do since he's only there part time bc he got complaints from the regulars for not filling them that day or for telling them that next time it would not be the same day as the apt. They called the manager and was saying taking business somewhere else or whatever and since business is key for that independent. The manager talked to him saying that he's being considerate to other human beings. I feel so bad for my friend but I don't know what kind of advise to give him btw him and his manager. Any other pharmacist have any suggestions?

 

[BenJammin]

After Walgreens got fined millions of dollars for giving out controlled substances like it's Halloween next door to the elementary school, I don't think they'll have a problem with you turning away a suspicious script. Hell some chains don't even count controlled substances into their script count tied to bonuses.

 

[Ackj]

Since this topic was brought up, i have a question on a situation. My fellow rph was telling me about his situation. He works at PT at a independent where each customer is pretty impt. His partner is willing to fill C2 in NY the day patients come in from their appointment because they live far away and small town mentality. Apparently everyone knows the manager. The patient's appointment is set up every 27 or 28 days so i guess the pt wants to fill it the day of the apt for convenience sakes so my friend who is a new grad doesn't know what he should do since he's only there part time bc he got complaints from the regulars for not filling them that day or for telling them that next time it would not be the same day as the apt. They called the manager and was saying taking business somewhere else or whatever and since business is key for that independent. The manager talked to him saying that he's being considerate to other human beings. I feel so bad for my friend but I don't know what kind of advise to give him btw him and his manager. Any other pharmacist have any suggestions?

Law is clear for NY and early fills. If it is a recurring problem, perhaps they should change the dates of their appointments, have the rx mailed, etc. Literally thousands of patients get a chronic CII medication every 30 days without any issues, there is no reason those patients should be any different.

 

[icekitsune]

Law is clear for NY and early fills. If it is a recurring problem, perhaps they should change the dates of their appointments, have the rx mailed, etc. Literally thousands of patients get a chronic CII medication every 30 days without any issues, there is no reason those patients should be any different.

Those are pretty good suggestions, I will let him know though Idk if they are willing to change at all. This is kinda interesting though. He told me that some of the older pharmacists was taught that life of a prescription is life of the rx, not life of therapy. For example, oxycontin 10 30 day supply, you can theoretically get 7 days early in December. When they bring in another c2 script in January, you can techniqually get it fill another 7 days early since the life of the rx is only "30 days". For C3-C5, since the rx has refills, the life of the prescription is 7 days early in the span of those 6 months. Its not how I was taught

 

[zelman]

Those are pretty good suggestions, I will let him know though Idk if they are willing to change at all. This is kinda interesting though. He told me that some of the older pharmacists was taught that life of a prescription is life of the rx, not life of therapy. For example, oxycontin 10 30 day supply, you can theoretically get 7 days early in December. When they bring in another c2 script in January, you can techniqually get it fill another 7 days early since the life of the rx is only "30 days". For C3-C5, since the rx has refills, the life of the prescription is 7 days early in the span of those 6 months. Its not how I was taught

It's not how you were taught for a reason.

"Except as provided in subdivision (d) of this section, no such prescription shall be made for a quantity of substances which would exceed a 30-day supply if the substance were used in accordance with the directions for use, as specified on the prescription. No additional prescriptions for a controlled substance may be issued by a practitioner to an ultimate user within 30 days of the date of any prescription previously issued unless and until the ultimate user has exhausted all but a seven days' supply of that controlled substance provided by any previously issued prescription."

-- Title: Section 80.69 - Schedule III, IV and V substances

"(c) Except as provided for in subdivision (d) of this section, no such prescription shall be made for a quantity of substances which would exceed a 30-day supply if the substance were used in accordance with the directions for use, specified on the prescription. No additional prescriptions for a controlled substance may be issued by a practitioner to an ultimate user within 30 days of the date of any prescription previously issued unless and until the ultimate user has exhausted all but a seven days' supply of that controlled substance provided by any previously issued prescription."

-- Title: Section 80.67 - Schedule II and certain other substances

 

[icekitsune]

It's not how you were taught for a reason.

"Except as provided in subdivision (d) of this section, no such prescription shall be made for a quantity of substances which would exceed a 30-day supply if the substance were used in accordance with the directions for use, as specified on the prescription. No additional prescriptions for a controlled substance may be issued by a practitioner to an ultimate user within 30 days of the date of any prescription previously issued unless and until the ultimate user has exhausted all but a seven days' supply of that controlled substance provided by any previously issued prescription."

-- Title: Section 80.69 - Schedule III, IV and V substances

"(c) Except as provided for in subdivision (d) of this section, no such prescription shall be made for a quantity of substances which would exceed a 30-day supply if the substance were used in accordance with the directions for use, specified on the prescription. No additional prescriptions for a controlled substance may be issued by a practitioner to an ultimate user within 30 days of the date of any prescription previously issued unless and until the ultimate user has exhausted all but a seven days' supply of that controlled substance provided by any previously issued prescription."

-- Title: Section 80.67 - Schedule II and certain other substances

Its funny (not really) but my friend actually called the BNE today and they couldn't give him a straight answer when he provided the exact same example as above. The whole 28 days appointment/fill (so 2 days early each time). All he was told from the BNE was that watch for those who come back and fill the exact same thing but those that are "like clockwork" its fine and not abusing it, even though my friend was trying to explain that after 4 months, the patient will have atleast 8 extra pills. BNE told him that..well what if the pt was on the same med for 10 years, you can't calculated that far. I got the impression that the person my friend talked to wasn't clear himself about the rules.

 

[zelman]

Its funny (not really) but my friend actually called the BNE today and they couldn't give him a straight answer when he provided the exact same example as above. The whole 28 days appointment/fill (so 2 days early each time). All he was told from the BNE was that watch for those who come back and fill the exact same thing but those that are "like clockwork" its fine and not abusing it, even though my friend was trying to explain that after 4 months, the patient will have atleast 8 extra pills. BNE told him that..well what if the pt was on the same med for 10 years, you can't calculated that far. I got the impression that the person my friend talked to wasn't clear himself about the rules.

My rule of thumb when I worked in NY was to go back to the last change in dose. That is rarely a ten year commitment.